- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,187.16 / $5,187.16 / $5,187.16
| Facility | | $5,187.16 | $5,187.16 | $5,187.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,187.16 / $5,445.78 / $5,928.19
| Professional | | $5,187.16 | $5,445.78 | $5,928.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,553.03 / $6,553.03 / $6,553.03
| Facility | | $6,553.03 | $6,553.03 | $6,553.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,783.71 / $6,553.03 / $6,553.03
| Professional | | $4,783.71 | $6,553.03 | $6,553.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,920.30 / $7,261.04 / $46,975.22
| Facility | | $2,920.30 | $7,261.04 | $46,975.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,015.68 / $5,977.56 / $11,806.22
| Professional | | $3,015.68 | $5,977.56 | $11,806.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,015.68 / $5,451.23 / $6,814.04
| Professional | | $3,015.68 | $5,451.23 | $6,814.04 |